Come Dec. 1, the target date for changes ordered last week by the Jefferson County Commission, the venerated health care institution for the county's indigent residents will still occupy its building on Sixth Avenue South. Its outpatient clinics will still see and treat the sick. And walk-in care still will be provided 24 hours a day, seven days a week, said County Manager Tony Petelos.

"Our patients will continue to be served, and none will be left on the street," he said.

But at least three major changes are coming, Petelos said:

• That 24/7 walk-in service at Cooper Green will be urgent care, not an emergency room, meaning it will handle problems that require immediate attention but are not life-threatening.

• Cooper Green patients who need to be admitted to a hospital will go to some other hospital -- sites still to be determined through agreements between the hospitals and the county -- and Cooper Green will shutter its inpatient hospital care.

• Many of Cooper Green's staff will lose their jobs. In addition to about 100 who have been cut since March, Petelos said he expects more than 200 layoffs. The hospital employs 528 people.

"The staff of Cooper Green is very upset," he said. "There is a lot of uncertainty."

Outside the hospital, rumors swirl, and patients and public stakeholders show a mounting worry and distrust.

Petelos said he understands those reactions.

"I'm a lifelong resident of Jefferson County," he said. "I know what Cooper Green Hospital meant to the people of Jefferson County. There's two aspects of Cooper Green. It was a building that's like a landmark, and then there's the other side to it. There's the services they provide.

"But it's an old model," he said. "The model is broke."

The county has been spending more than $10 million a year from its general fund on the hospital, above the $43 million a year in taxes earmarked for indigent care. "Jefferson County is in bankruptcy," Petelos said. "Our job, the county manager's office, is to make this (change) happen. I told the commissioners, we will work very hard to develop the system, and have them within their budget."

Chance for innovative care?

While the commission tries to put out fiscal fires, some see opportunity in the Cooper Green crisis.

One is Dr. Max Michael, dean of the University of Alabama at Birmingham's School of Public Health and former head of Cooper Green.

"I understand all the angst," Michael said. "But I do think there is a chance for Jefferson County to truly create an innovative system of care that will actively improve the health and well-being of the people of Jefferson County -- not just a person, a population."

Michael came to Birmingham from Boston as a UAB intern in internal medicine in 1972, and he became one of the first doctors to work in Cooper Green when it opened that October.

"At the time, it was the most modern, up-to-date hospital in this community," he said.

"Now you have people who have been part of the system, recognizing the system is both the health department (and) Cooper Green," Michael said. "Over the course of the latter 30 percent of the 20th century, Cooper Green created a broad-based access to health care that didn't exist in the community before. That has done a lot to improve the health and well-being of the community."

Medicine itself has changed tremendously in the last 40 years, from an emphasis on inpatient care to outpatient care, and now preventive care.

"It is time for the county transition to a model that is more appropriate to the needs of the community in the 21st century," Michael said.

The cornerstone: Primary care

This spring Michael and health care executive Martin Nowak updated a report on the best way for the county to provide health care to the indigent, presenting three different plans and estimated capital and operational costs for each. [Read the report.] They acted at the request of Jefferson County lawmakers, led by Rep. Paul DeMarco, R-Homewood, as lawmakers of both political parties were considering reviving the county's occupational tax but linking it to a cut in indigent care funding.

The best of the three plans, Michael and Nowak concluded, was a comprehensive "hub and spoke" model that "can meet many of the needs of all stakeholders while maintaining the long-term fiscal integrity of the county and the state."

"The presumption was that primary care is the cornerstone of community health," Michael said. "For us, primary care came first; everything else comes after that. The presumption is with the other hospitals, if you do this right, then the burden of unnecessary emergency room visits and unnecessary hospitalizations gets reduced over time."

In the model, the central hub would offer 24/7 urgent care, as well as primary care, specialty care and diagnostic services. The spokes would be two primary care facilities at sites chosen to improve regular access to care in needy areas.

Inpatient care now provided by Cooper Green would be shared by all the other hospitals in the county, where "the quality of the facilities and the quality of the technology is far superior to what Cooper Green has."

"Cooper Green has $30 million of capital needs," Michael said. "People who need the care deserve something that is 21st-century care, not mid-20th century."

Devil in the details

But Michael said "the devil is in the details" in how to divvy the inpatient shares among the hospitals and how much to pay them out of indigent care fund dollars.

"If we're going to partner and create a system, the hospitals have to participate," he said. The number of inpatients at Cooper Green is only 2.7 percent of the average daily number of inpatients in Jefferson County hospitals, according to data collected by the State Health Planning and Development Agency. That total does not include Children's of Alabama.

Petelos and the Jefferson County Commission face that same devil-in-the-details problem of how to pay other hospitals for indigent inpatient care and then get the patients back into their Cooper Green primary care system. As one step toward figuring that out, Petelos and other county administrators met with the doctors' group Jefferson County Medical Society on Monday.

Dr. Darlene Traffanstedt, president of the medical society, which represents about 2,300 physicians from all hospitals, said the organization wants to be a voice for the patients and for the doctors.

"Our ultimate goal is that the patients get the care they deserve and that our physicians be actively involved in the solution since they will be caring for the patients," she said.

Traffanstedt said if the society is not contacted next week by county officials, it will reach out to the county again to offer assistance.

The Dec. 1 target date could be delayed, Petelos said, because all the proper licenses from state regulators have to be in place before the change is made as well as agreements with hospitals that choose to participate.

"Those are very detailed issues we have to deal with," he said. "I don't know the details, but I do know we will continue to provide services to the people of Jefferson County and serve patients at Cooper Green Hospital.

"I don't know what's going to happen," he said, "but we're up to the job and we'll make it happen."

Commission President David Carrington and Commissioner Jimmie Stephens, two of three commissioners who voted to end inpatient service, agreed that service would not end at the hospital on the targeted date without an implementation plan and agreements with participating hospitals in place.

'Too many unanswered questions'

Maralyn Moseley, 74, a longtime Cooper Green advocate, remains skeptical of the models of care for indigent patients being discussed.

Moseley said too many questions remain, including just how much money there is in the indigent care fund. She rattles off questions such as, "Who will pay the cost of ambulance service if a patient needs to be transported from urgent care to a hospital?"

"Who has really thought this out?" she said. "I don't know how they are going to do it. I have come to the conclusion that your actions speak louder than your words. So far, what I have heard from the County Commission has been a lot of words, but their actions have belied their words. There are too many unanswered questions, and now the commissioners are running around trying to catch up."

Moseley said she is worried that patients will be frightened off because of the uncertainty and lack of clear direction. She believes the county has to do some kind of outreach to the more than 50,000 people who hold "blue cards," an insurance card Cooper Green Mercy Hospital gives to indigent residents, to let them know what is happening.

"I don't know if someone is working on that," she said.

Cooper Green also serves the Jefferson County Sheriff's Office in providing medical care and treatment to inmates at the Jefferson County jail. Questions about that care remains in the air as well.

Chief Deputy Randy Christian said the office will be speaking to other area hospitals in the coming weeks to work that out and secure a plan.

'Incredible opportunity'

Both Stephens and Carrington said they are leaning toward considering Michael's "hub and spoke" model more closely.

His model included an aggressive timeline -- transition to Cooper Green Health Services Inc. within 90 days, conduct community conversations and stakeholder meetings to review its proposed replacement facilities and fundamental operational issues during the next 120 days, and begin construction of new facilities about five months after that.

Michael said the word "close" was never used in his and Nowak's report, "Fulfilling Historic Commitments and Obligations: A proposal for a 21st century health care system for Jefferson County."

"It's 'transition.' Get out of inpatient care; transition the emergency room to urgent care that is still 24/7," he said.

Changing the health care model for the county's indigent population, if done right, should be seen in a hopeful light, Michael said.

"Quit gnashing your teeth. This is really an opportunity to improve the health and well-being of the community," he said. "I think this is an incredible opportunity for the county to put itself on the map."